Youth Concussions

Over the past three years, 17 high school football players have died after sustaining head injuries while playing. A similar situation in the NFL would have caused a national uproar, so how has this been allowed to happen to our youth?

Take a look at trailer for this riveting episode of HBO’s series Real Sports with Bryant Gumbel, which is airing several times on HBO through mid-December 2016, as well as On Demand. The episode as a whole explores why there are such inconsistencies in protecting professional athletes versus the youngest players.

Lots of myths and misinformation exist about how parents and coaches can supervise the recovery of a child’s concussion. Some of the most common ones stem from advice that was given years ago. But better understanding of brain injuries and new imaging technology has changed how concussions are treated. Here’s what NOT to do when managing your child’s injury.

1 — Waking Every Hour or Two
Decades ago, physicians and clinicians encouraged parents to wake up their concussed children frequently to monitor their mental status. However, with modern imaging and clinical evaluations, patients who have been cleared by a concussion specialist can sleep soundly. In fact, remaining asleep 12, 15 or even 20 hours following a head injury is actually helpful, restful, and promotes faster recovery.

2 — Return to the Game Too Soon
Most concussion laws in every state have a provision in which a child is removed from play when a concussion is suspected and can only be cleared to return by a concussion specialist. Unfortunately, clinicians will periodically encounter an overly ambitious parent wanting to return his or her child to play prior to making a full recovery from the concussion. Depending on the timing, this can be exceedingly dangerous. If it is too soon, the child may be in danger of secondary impact syndrome, which can be fatal.

3 — Keep Away from Friends and Electronic Devices
Socialization is an important part of adolescent development. Keeping a child completely isolated from friends and electronic devices can lead to a sense of isolation, and in some cases, even depression. Clinicians and parents need to be mindful of balancing remediation with a young person’s sensitive self-esteem.

4 — Promote Completely Inactivity and Darkened Rooms
Although some rest is thought to be useful from 48 to 72 hours after the head injury, extensive rest and inactivity in a dark room is actually thought to do more harm than good. The brain can actually have more difficulty to returning to normal activity following an extensive period of inactivity.

A number of research articles suggest that women are more susceptible to mild Traumatic Brain Injury. In fact, female college athletes have a higher rate of concussion compared to males when playing soccer (2.1 x greater risk), softball versus baseball (up to 3.2 x greater risk), and basketball (up to 1.7 x greater risk). So, why the difference? Research and anecdotal evidence has turned up three possible reasons: cultural differences; hormonal differences, or physiological differences.

Canada forward Christine Sinclair (right) and USA midfielder Carli Lloyd head the ball during the 2016 CONCACAF women’s Olympic soccer tournament at BBVA Compass Stadium in Huston, Texas, on February 21. Soccer is also among those sports programs that produce a large share of concussions for female athletes. — Reuters

Some experts have said part of the reason for increased concussions in females may be due to the reporting rate — that women are more likely than men to notify a coach they are injured, whether due to a head injury or other concern. Cultural differences indeed indicate a reluctance among males to report any injuries for fear of being removed from play. However, because of the very nature of concussion being a clinical diagnosis that usually depends on self reporting, it is hard to say that the incidence differences between the genders is due to honesty.

Other research suggests that hormones including estrogen, oxytocin, progesterone, and testosterone, affect recovery times from concussion. Of course, men and women have vastly differing levels of these hormones. One published study from the University of Rochester (NY) has also shown that menstrual cycles play a part in healing from head trauma. The research showed that women in child-bearing years experience greater cognitive decline, delayed reaction times, extended periods of depression, more headaches, and longer hospital stays and return-to-work plans compared to men following head injury.

Other research suggest that there are different neuronal connections between the hemispheres and significant lobes within the cerebral cortex for men and women potentially influencing recovery time. A recent Georgetown University Medical Center study showed that mice with a single head injury temporarily lose 10 to 15 percent of the neuronal connections in their brains, which can be repaired when at least a week of rest is provided. The fact that male and female brains are “wired” differently could account for a higher incidence of and/or a longer healing period after brain injury in women.

Realistically, interplay of all of these factors could potentially influence the differences in concussions between the number of concussions of female athletes and their recovery.

Periodically when I’m seeing patients in our HeadFirst concussion clinics, parents will ask me about a different brain trauma-related studies that they’ve heard about. These questions range from studies about concussion-healing chocolate milk to eye tracking devices to the effectiveness of helmets and different sports bands preventing head injuries. Presently, NO concussion treatments have been approved by the United States Food and Drug Administration (FDA). Likewise, the FDA has yet to approve of any devices that prevent concussions in the first place. No helmets, no mouth guards, no sports band or other piece of technology in any way shape or form has been demonstrated to completely prevent concussions.

I typically advise parents to be extremely cautious with new research or technology, or with the promises of concussion treatment. Instead, parents should seek out a concussion specialist who has years of experience treating these injuries and utilizes multiple methods in their assessment, diagnosis, and treatment planning.

CTE’s connection to football has been in the news for five years now, with a debate centered around whether the number of concussions will affect long-term health and well-being of those playing the sport. Likewise, I’m constantly asked by patients and parents what the future effect of this or future concussions will be on their health. A recent study released by researchers at the Boston University School of Medicine (such as Dr. Robert Cantu, Dr. Ann McKee, Chris Nowinski and others) will probably give moms and dads across America a moment of pause before starting a collision sport like football or hockey.

An answer may lie in a concept developed by these researchers called the Cumulative Head Impact Index (CHII). They found individuals who had more hits to their heads—regardless of whether they had a concussion or not, were significantly (i.e., not even close…a large statistic margin) more likely to experience later-life cognitive problems, apathy and depression. The caution here is that the sample size was only 93 individuals and the exposure was only to football.

The next step is for medical providers and concussion specialists to help families begin to connect the dots throughout the developmental hurdles of a child’s life. For example, the health outcomes for two 7th grade beginning hockey players if they have a different history. One student may have fallen off a changing table as an infant and suffered a skull fracture, have been in a motor vehicle accident, and have fallen multiple times during winter sports, while the other 7th grader may not have suffered any head injuries or significant head trauma. Baseline neurocognitive testing like the ImPACT® test might look different on these two young students, and the outcome and recovery time of any current injuries sustained by each of them could be considerably different.

I’ve often said that kids can’t live in a bubble as much as parents are sometimes inclined to want to wrap their kids in bubble wrap. Young people—really, people of all ages—are going to be in car accidents, bike accidents, and slip and fall just going through life. Parents need to make their own unique, informed decision about how much additional risk of physical injury to which they want to expose their child, given his or her medical history and athletic abilities.

The much-anticipated movie “Concussion” is scheduled for release this year on Christmas Day, and already there is Oscar Award talk for Will Smith, who plays the role of Dr. Bennet Omalu. It was Dr. Omalu who discovered the tragic progressive degenerative effects of years of multiple concussions in NFL players, which he named CTE (chronic traumatic encephalopathy).

Bennet Omalu, M.D., (L) and actor Will Smith attend the screening of the major motion film, “Concussion,” on November 23, 2015. (VALERIE MACON/AFP/Getty Images)

The film highlights the NFL’s initial response of anger and denial. Indeed, since Dr. Omalu’s discovery in 2002, the NFL has experienced lawsuits, exposés, and finger-pointing in general. Now, 13 years later, bystanders have watched the NFL’s reaction to this scientific research unfold in a manner not unlike many stages of grief – first denial, then anger, on to bargaining and, finally, acceptance. (Although, the League is still working on fully coming to terms with this last step.)

For their part, the NFL hasn’t had much reaction to the movie, preferring to keep the controversy at arm’s length. While Dr. Omalu has vocalized his opposition to children playing football until they are legally and emotionally old enough to understand the danger of putting their brains at risk, the NFL can’t afford to lose any of their reported $7+ billion in annual revenue.

Yet, while the debate rages on, two points are patently clear from years of scientific research: that children repeatedly hitting their heads during developmental years is potentially very harmful, and that college and professional football players can face significant health consequences from playing the sport.

But just how serious are families going to be about keeping their children from playing football? Indeed, this is just the beginning of the conversation about brain injuries.

As a community-based concussion clinic that has treated more than 30,000 traumatic brain injury patients over the past three years, HeadFirst Concussion Care has seen multiple reasons for why people sustain concussions. And while football is a violent sport, soccer, lacrosse and hockey also put our youth at risk for head trauma.

And again, this is just half of the dialogue. HeadFirst’s data shows that traumatic brain injuries sustained while playing organized sports with a concussion protocol in place (high school or college sports) account for a relatively small percentage of our patients. In fact, in as many as 80 percent of our patients, concussions are sustained by other mechanisms of injury. These include non-organized sports-related injuries (bike riding, skateboarding, trampolining, skiing, pick-up or other informal recreational games), slips and falls, motor vehicle accidents, and assaults.

The key message is that the people must understand that traumatic brain injuries can happen to anyone, anywhere, at any time. Not just kids. Not just athletes. And certainly, not just NFL players. And since anyone is at risk, everyone must understand the proper protocols for healing an injured brain.

On a final note to end the year, my holiday wish is that families, schools, and employers begin to talk about head injuries and follow traumatic brain injury protocols to keep all children and adults safe.

A recent study published in American Academy of Pediatrics June 2015 Pediatrics (published online on May 11, 2015) looked at concussion and its effect on academic performance. The research included a sample of 349 students, ages 5 to 18, who sustained a concussion and whose parents reported post-injury academic concerns on school questionnaires. The type and intensity of the students’ concussion symptoms were measured as an indicator of the severity of their injury.

Researchers found that actively symptomatic students and their parents had heightened concerns over the effects of the students’ concussions on their school performance, as well as increased school-related problems than their recovered peers. In other words, the students’ level of post-concussion symptoms had a direct relationship to the extent of academic effects.

Eighty-eight percent of students with symptoms reported school problems due to headaches, fatigue and concentration issues, while 77 percent reported issues such as needing to spend more time on homework, difficulty taking notes, and studying.

Additionally, high school students in the study who had not yet recovered reported significantly more adverse academic effects than their younger counterparts. The greater the severity of their concussion symptoms was also associated with more school-related problems and worse academic effects, regardless of time since injury.

Every state has concussion legislation generally requiring three basic criteria in the event of a concussion:

The removal of a child from play

A structured return to learn

Clearance from a concussion specialist

However, most youth aren’t athletic professionals and many of them do not advance to participate in college and professional athletics. Currently, only Nebraska and Virginia have return-to-learn legislation indicating that concussed athletes may need specific informal or formal accommodations at school and that school personnel should be trained in concussions. In light of students’ limited number of years of sports and because of recent proven research, legislation should be in place in every state to provide more extensive accommodations after a brain injury so that students’ academics are not adversely affected.